Review

Correspondence *McGill University Faculty of Medicine, Department of Surgery, Montreal, Quebec, Canada

Email mostafa.elhilali@muhc.mcgill.ca

Introduction

Benign prostatic hyperplasia (BPH) is a common urological disorder. One population-based study, published in 2001, suggests that it might affect up to 8.4% of men aged 40–49 years and 33.5% of those aged 60–70 years (Box 1).¹ In the 20th century, open surgical management of BPH became popular. A relatively high-morbidity and expensive procedure, open prostatectomy was gradually replaced by transurethral resection of the prostate (TURP) as the standard surgical treatment of small to medium sized BPH. High success rates, lower costs and shorter recovery times after TURP were among the factors contributing to the gradual replacement of open prostatectomy; however, TURP is associated with considerable complications, including the need for blood transfusions in 2.0–4.8% of patients and the occurrence of transurethral resection (TUR) syndrome in 0–1.1% of patients.² Eight-year follow-up data on a large cohort of 23,123 men who underwent TURP showed a cumulative incidence of repeat endourological interventions of 14.7%.³ The incidence of TUR syndrome increases with a gland size greater than 45 g and resection times longer than 90 min.⁴

Over the past 15 years, numerous alternative procedures have been introduced with the goal of achieving comparable results to TURP, while minimizing morbidity and cost. Many of these alternative procedures have not fulfilled these objectives, while a few maintain the potential to replace TURP owing to the promising results from several methodologically sound, prospective, randomized controlled trials. In this Review, we examine the most commonly discussed surgical procedures, among the current literature, that are used to treat BPH, with special emphasis on original research.

Transurethral incision of the prostate

Transurethral incision of the prostate (TUIP) involves making an incision at the 5 and 7 o'clock positions from distal to the corresponding ureteral orifice to the level of the verumontanum on the ipsilateral side, extending the depth of the incision to the surgical capsule. This procedure is usually performed in patients with small prostates (<40 g). Several randomized trials^{5, 6, 7} have compared TUIP with TURP, with comparative results. TUIP has a shorter procedure time and is associated with a lower risk of retrograde ejaculation, while some studies indicate that TURP is associated with a slight improvement in urinary symptoms.

A randomized trial by Aho and colleagues⁸ compared outpatient holmium laser TUIP with holmium laser enucleation of the prostate (HoLEP) in men with prostates smaller than 40 g.⁸ TUIP was associated with a shorter procedure time and a lower risk of retrograde ejaculation, whereas HoLEP was associated with better postoperative urodynamic findings, smaller postoperative prostate size on transrectal ultrasonography (TRUS) and a higher incidence of transient stress urinary incontinence.

Bipolar techniques

In conventional (monopolar) TURP, electrical current passes through the patient from the active electrode (connected to the resectoscope loop) to a grounding pad attached to the patient; this has potential risks, such as skin burns, excessive heating of deep tissues, nerve damage,⁹ inadvertent nerve stimulation (e.g. obturator reflex) and cardiac pacemaker malfunction.¹⁰ Additionally, conventional TURP requires nonhemolytic, hypo-osmolar irrigation fluids (e.g. glycine), which, if absorbed in high volumes, may lead to TUR syndrome. In an attempt to address some of these disadvantages, bipolar technology was proposed as an alternative treatment for BPH.

Bipolar transurethral resection of the prostate

Bipolar TURP has similar benefits to bipolar TUVP, in addition to its capability of providing resected tissue that can be submitted for histopathological assessment. Bipolar TUVP is technically similar to conventional TURP, which implies a short learning curve for training surgeons. In bipolar TURP, resectoscope loops of varying shapes are used, but the general concept is essentially the same as that of conventional TURP. Electricity runs between an active and a passive electrode, converting the irrigation solution (i.e. normal saline) into a plasma layer which disintegrates tissue on contact.¹⁷ Several devices have been assessed, some of which have been modified or withdrawn. A review of the technical differences between these devices has been reported by Rassweiler and colleagues.¹⁸

Since the safety and efficacy of bipolar TURP was first reported,^{19, 20} at least 11 randomized trials have assessed its use (Table 1).^{21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31} In most of these studies, preoperative prostate volume was around 40–55 ml. Resection time was comparable between bipolar TURP and TUVP in most studies.^{22, 23, 24, 26, 27, 29, 30, 31} Interestingly, the largest two studies showed opposing results on which technique resulted in better resection times;^{21, 25} the group that reported shorter resection times with bipolar TURP, however, did not comment on the weight of the resected tissue, nor did they perform postoperative TRUS or PSA assessment. A hybrid technique that uses bipolar TUVP for the median and lateral lobes and bipolar TURP for apical tissue resection and histopathological specimen extraction was also reported to be faster than monopolar TURP.²⁸ None of these studies showed a difference in the weight of the resected tissue between the two techniques, including the study that showed a shorter resection time with monopolar TURP.^{22, 23, 25, 26, 27}

Table 1 Prospective, randomized trials that compare monopolar TURP with bipolar TURP.

Full tableFigures & Tables indexDownload Power Point slide (316K)

Intraoperative blood loss is usually assessed either by immediate (within 24 h) postoperative measurement of hemoglobin or hematocrit levels^{22, 23, 24, 25, 26, 29, 30} or by other methods or techniques.^{27, 31} Two studies have reported that the bipolar technique resulted in significantly less blood loss than monopolar TURP.^{29, 31} In a third study, while intraoperative blood loss was not assessed, the number of patients requiring blood transfusions was significantly higher in the monopolar TURP group than in the bipolar TURP group.²¹ Additionally, five randomized, prospective studies^{22, 25, 26, 27, 30} reported that there was a less signigicant decline in serum sodium levels after bipolar TURP. Eight studies^{21, 23, 24, 27, 28, 29, 30} found significantly shorter postoperative catheterization times and five studies revealed significantly shorter hospital stays with bipolar TURPs compared with monopolar TURP (Table 1).

Although postoperative improvements in IPSS and QOL at 3 years were comparable between monopolar and bipolar TURP in all studies,³² two studies reported significant improvements in Q_max 1 year after bipolar TURP.^{21, 28} Nevertheless, the clinical significance of these differences may be questioned (Table 1). Postoperative urine storage symptoms varied between the two techniques; the rate of postoperative urinary storage symptoms was higher after bipolar TURP in one study,²⁸ whereas it was higher after monopolar TURP in two other studies.^{21, 27} Urethral stricture rates were significantly higher with bipolar TURP in one study,²⁸ and they were high in another study,²² but this was not statistically significant (3 patients vs 1 patient, P >0.05). The high ablative energy used, in addition to a larger resectoscope size (27 Fr vs 26 Fr), were proposed causes for this difference in stricture rates.²⁸ Ho et al.²² used a 26 Fr resectoscope for both bipolar TURP and TUVP procedures, and excluded any leakage of current along the instrument's sheath as a potential cause. Another study also reported substantial urethral injury rates during the insertion of a 27 Fr resectoscope, in addition to significantly higher meatal stricture rates with the bipolar technique.²¹

Laser procedures

Several laser techniques have been assessed for the treatment of BPH, including visual laser ablation of the prostate (VLAP), interstitial laser coagulation of the prostate, holmium laser resection of the prostate (HoLRP) and holmium laser ablation of the prostate (HoLAP).^{34, 35, 36} In this Review, however, we will focus on a few techniques that have been more thoroughly investigated and show the most promise for the treatment of BPH, including HoLEP, photoselective vaporization of the prostate (PVP) and thulium laser resection of the prostate (TmLRP).

Holmium laser enucleation of the prostate

HoLEP uses the resectoscope in a similar way to when a surgeon performs an open prostatectomy; that is, the surgeon uses his finger to separate the adenoma from the surgical capsule and achieve a truly anatomical enucleation, as described by Gilling and colleagues.³⁷ In HoLEP, the adenoma is pushed into the bladder by the resectoscope and removed using a tissue morcellator. Normal saline is used as the irrigant to lessen the risk of TUR syndrome. HoLEP is the most extensively studied laser technique for the treatment of BPH.

HoLEP versus monopolar TURP

At least six randomized trials from four different investigator groups have compared HoLEP with monopolar TURP (Table 2).^{38, 39, 40, 41, 42, 43, 44, 45} One group used the mushroom technique (resection of devascularized lobes with electrocautery, using hypotonic irrigants, while still attached to the capsule by a thin pedicle) instead of a tissue morcellator.^{39, 42} Mean prostate size in both studies ranged from 53.5 g to 77.8 g; patients in the HoLEP group had significantly larger glands than patients in the monopolar TURP group.^{40, 43} In all trials, procedure length was significantly shorter in the TURP group. Specimen weight after HoLEP was significantly larger than after TURP in two trials,^{43, 45} but was larger after TURP in another trial.⁴¹ In yet another trial, procedure time was comparable between both techniques.⁴² Gupta and colleagues⁴¹ attributed the small specimen weight in the HoLEP and TUVP groups to the substantial vaporization effect and the relatively small prostate sizes in the study. In another trial, Tan and colleagues⁴⁵ compared the efficiency of the two techniques by assessing the mass of specimen removed per minute of energy source used; HoLEP was significantly more efficient than TURP, despite the longer surgery time during the HoLEP procedure. Although blood loss was significantly lower during HoLEP than TURP in two studies, the clinical significance of these findings is questionable.^{41, 42} The reduction of serum sodium levels was similar in both techniques.^{41, 42} Early postoperative dysuria was more frequent in patients after HoLEP in two studies.^{41, 43} Few other differences in complication rates were reported between the two techniques. Catheterization time and hospital stay were consistently shorter in the HoLEP groups.^{41, 42, 43, 45} The differences in IPSS, QOL, Q_max and changes in sexual function were generally comparable between the two techniques.^{38, 39, 40, 41, 42, 43, 44, 45}

Table 2 Prospective, randomized trials that compare monopolar TURP to various laser procedures.

Full tableFigures & Tables indexDownload Power Point slide (299K)

HoLEP versus open prostatectomy

Two randomized trials compared HoLEP with open prostatectomy in patients with a mean prostate size of 113–124 ml.^{46, 47} Although the weight of the removed specimen was significantly higher with open prostatectomy in both trials,^{46, 47} this difference disappeared with correction for estimated tissue loss to vaporization.⁴⁷ Procedure time was significantly shorter for open prostatectomy compared with HoLEP, and HoLEP was associated with less blood loss and transfusion requirements as well as shorter catheterization and hospitalization times.^{46, 47} Transient dysuria was reported during the early postoperative period more commonly in patients who underwent HoLEP than in those who underwent open prostatectomy.⁴⁷ The two procedures were comparable in terms of IPSS, Q_max and PVR urine volume, in addition to the incidence of long-term complications (up to 5 years).^{47, 48} HoLEP was also found to provide significant net cost savings compared with open prostatectomy for patients with large prostates (>70 g).⁴⁹

HoLEP has also been reported to be safe and effective for the treatment of patients with urinary retention,^{50, 51} patients who are critically ill,⁵² and those with bleeding disorders or who are receiving anticoagulants.⁵³ Moreover, HoLEP can be used to simultaneously treat BPH with bladder or upper urinary tract stones.^{54, 55}

Laparoscopic simple prostatectomy

Laparoscopic simple prostatectomy, via either the transvesical or the preperitoneal approach, has been assessed in patients with BPH.^{66, 67} Retrospective studies comparing this technique with open prostatectomy showed similar improvement parameters and complication rates as well as reduced blood loss, catheterization time and hospital stays and longer operation times with the laparoscopic approach.^{68, 69} Blood loss and catheterization time, however, were considerably higher than those reported for transurethral procedures. These findings, in addition to the steep learning curve and with high costs, may reduce interest in this laparoscopic approach.

Robotic simple prostatectomy

Robotic simple prostatectomy has also been assessed in patients with BPH.⁷⁰ In seven patients, the mean procedure time, blood loss, catheterization time, drain time and hospital stay were 195 min, 381.6 ml, 7.5 days, 3.5 days and 1.33 days, respectively. The average cost was $12,093.

Discussion

In recent years, most patients with symptomatic BPH are started on pharmacological therapy. This treatment option has resulted in patients presenting at an older age with more comorbidities and larger prostates than usual after unsuccessful pharmacological therapy.⁷¹ These factors, coupled with the relatively high morbidity associated with the traditional options of intervention for BPH (i.e. open prostatectomy and TURP), have triggered the development of new treatment options for patients who do not respond to drug-based therapy or present with refractory urinary retention.

Currently, there is sufficient data to suggest that HoLEP has replaced open prostatectomy as the standard surgical treatment of BPH. HoLEP is associated with lower morbidity rates and is more cost-effective than open prostatectomy, with comparable long-term results. Thus, it would seem that the only role for open prostatectomy at present is when there is no access to HoLEP. Unlike most of the other available options, the benefits of HoLEP have been shown to be independent of prostate size.⁷²

The two main criticisms of HoLEP are its high costs and a steep training curve. Despite the considerable initial costs of the holmium laser equipment, it can also be used in the treatment of stones, urethral and ureteral strictures and superficial bladder tumors.⁷³ Furthermore, holmium laser fibers can be sterilized and reused, unlike KTP fibers, which are single use; as a result, the cost of holmium laser fibers is 5% of the cost of KTP fibers per patient.³⁶ The learning curve of HoLEP for use in patients with small to medium sized prostates is estimated to be 20–30 cases.^{36, 74} In a prospective assessment, Shah et al.⁷⁵ reported that an endourologist who is not familiar with the procedure can achieve outcomes comparable to experts with experience of about 50 cases.⁷⁵

PVP is emerging as a popular treatment modality for BPH, particularly in patients with small-sized and medium-sized prostates. The procedure has a relatively short learning curve and, like HoLEP, can be used in patients with significant comorbidities and those on anticoagulation therapy. Further evidence that supports the durability of PVP results is anticipated. Five-year follow-up results reported by Malek and colleagues,⁷⁶ although positive, represent only 14 of their original 94 patients.⁷⁶ Long-term evidence on the applicability of PVP to patients with large prostates is presently not available. There are concerns that this treatment modality may require that more patients have to be reoperated upon in light of the limited degree of reduction in PSA and TRUS volumes. Prominent median lobes might also pose a large challenge with this technique because the laser beam leaves the side-firing fiber at a 70° angle, increasing the potential risk of bladder injury. Another concern, among others, is that ablative methods do not leave tissue for histopathological assessment. Incidental detection of prostate cancer on transurethrally resected specimens is usually 5.2–7.4%, and has even been reported as high as 19%.^{25, 77, 78} Although the KTP laser is not used for stone treatment, it has been assessed for the treatment of urethral strictures.⁷⁹

Bipolar TURP also seems to be a promising option for treating small to medium sized prostates, pending long-term results. The technique has not yet been tested on large prostates in prospective, randomized controlled studies. Bipolar TURP is also proposed as a safe way of providing training in transurethral resection techniques for urology residents.⁸⁰ Bipolar resection devices can also be applied to removing bladder tumors without the risk of perforation owing to the obturator reflex.⁸¹

Conventional and robotic laparoscopic prostatectomies remain as new methods of treating BPH that are under investigation. In our opinion, these procedures represent an exploration of the limits of these technologies' application. TUIP can be performed as an outpatient procedure, but is reserved for small prostates (<40 g). Minimally invasive treatment options for BPH, such as transurethral microwave thermotherapy, transurethral needle ablation, high-intensity focused ultrasonography and water-induced thermotherapy, have not been discussed here owing to space limitations, but have been recently reviewed thoroughly.⁸² In general, the durability, quality of clinical response and cost effectiveness of these options are variable and, when taken together with a lack of correction for the possible sham effect of the procedure in some studies, render their long-term outcomes questionable. Some of the more durable options are associated with increased morbidity and patient discomfort.

Conclusions

As more data accumulate, the roles of the different surgical treatment options for BPH are becoming better defined. The role of some procedures (e.g. open prostatectomy) in the management of BPH is diminishing, while the use of other modalities is increasing. Hopefully, with the aid of innovative technologies, urologists will continue to improve outcomes and minimize patient discomfort and morbidity when managing this common disorder.

Acknowledgments

Désirée Lie, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

References

1. Meigs JB et al. (2001) Risk factors for clinical benign prostatic hyperplasia in a community-based population of healthy aging men. J Clin Epidemiol 54: 935–944 | Article | PubMed | ISI | ChemPort |
2. Rassweiler J et al. (2006) Complications of transurethral resection of the prostate (TURP)—incidence, management, and prevention. Eur Urol 50: 969–979 | Article | PubMed |
3. Madersbacher S et al. (2005) Reoperation, myocardial infarction and mortality after transurethral and open prostatectomy: a nation-wide, long-term analysis of 23,123 cases. Eur Urol 47: 499–504 | Article | PubMed |
4. Mebust WK et al. (1989) Transurethral prostatectomy: immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3,885 patients. J Urol 141: 243–247 | PubMed | ISI | ChemPort |
5. Dorflinger T et al. (1992) Transurethral prostatectomy compared with incision of the prostate in the treatment of prostatism caused by small benign prostate glands. Scand J Urol Nephrol 26: 333–338 | PubMed | ChemPort |
6. Orandi A (1973) Transurethral incision of the prostate. J Urol 110: 229–231 | PubMed | ChemPort |
7. Riehmann M et al. (1995) Transurethral resection versus incision of the prostate: a randomized, prospective study. Urology 45: 768–775 | Article | PubMed | ChemPort |
8. Aho TF et al. (2005) Holmium laser bladder neck incision versus holmium enucleation of the prostate as outpatient procedures for prostates less than 40 grams: a randomized trial. J Urol 174: 210–214 | Article | PubMed |
9. Lefaucheur JP et al. (2000) Assessment of penile small nerve fiber damage after transurethral resection of the prostate by measurement of penile thermal sensation. J Urol 164: 1416–1419 | Article | PubMed | ChemPort |
10. Kellow NH (1993) Pacemaker failure during transurethral resection of the prostate. Anaesthesia 48: 136–138 | Article | PubMed | ChemPort |
11. Eaton AC and Francis RN (2002) The provision of transurethral prostatectomy on a day-case basis using bipolar plasma kinetic technology. BJU Int 89: 534–537 | Article | PubMed | ChemPort |
12. Hon NH et al. (2006) A prospective, randomized trial comparing conventional transurethral prostate resection with PlasmaKinetic vaporization of the prostate: physiological changes, early complications and long-term follow-up. J Urol 176: 205–209 | Article | PubMed | ChemPort |
13. Fung BT et al. (2005) Prospective randomized controlled trial comparing plasmakinetic vaporesection and conventional transurethral resection of the prostate. Asian J Surg 28: 24–28 | PubMed |
14. Dunsmuir WD et al. (2003) Gyrus bipolar electrovaporization vs transurethral resection of the prostate: a randomized prospective single-blind trial with 1 year follow-up. Prostate Cancer Prostatic Dis 6: 182–186 | Article | PubMed | ChemPort |
15. Karaman MI et al. (2005) Comparison of transurethral vaporization using PlasmaKinetic energy and transurethral resection of prostate: 1-year follow-up. J Endourol 19: 734–737 | Article | PubMed |
16. Kaya C et al. (2007) The long-term results of transurethral vaporization of the prostate using plasmakinetic energy. BJU Int 99: 845–848 | Article | PubMed |
17. Wendt-Nordahl G et al. (2004) The Vista system: a new bipolar resection device for endourological procedures: comparison with conventional resectoscope. Eur Urol 46: 586–590 | Article | PubMed |
18. Rassweiler J et al. (2007) Bipolar transurethral resection of the prostate—technical modifications and early clinical experience. Minim Invasive Ther Allied Technol 16: 11–21 | Article | PubMed |
19. Dincel C et al. (2004) Plasma kinetic vaporization of the prostate: clinical evaluation of a new technique. J Endourol 18: 293–298 | Article | PubMed |
20. Patel A and Adshead JM (2004) First clinical experience with new transurethral bipolar prostate electrosurgery resection system: controlled tissue ablation (coblation technology). J Endourol 18: 959–964 | Article | PubMed |
21. Erturhan S et al. (2007) Plasmakinetic resection of the prostate versus standard transurethral resection of the prostate: a prospective randomized trial with 1-year follow-up. Prostate Cancer Prostatic Dis 10: 97–100 | Article | PubMed | ChemPort |
22. Ho HS et al. (2007) A prospective randomized study comparing monopolar and bipolar transurethral resection of prostate using transurethral resection in saline (TURIS) system. Eur Urol 52: 517–522 | Article | PubMed |
23. de Sio M et al. (2006) Gyrus bipolar versus standard monopolar transurethral resection of the prostate: a randomized prospective trial. Urology 67: 69–72 | Article | PubMed | ISI |
24. Iori F et al. (2008) Bipolar transurethral resection of prostate: clinical and urodynamic evaluation. Urology 71: 252–255 | Article | PubMed |
25. Michielsen DP et al. (2007) Bipolar transurethral resection in saline—an alternative surgical treatment for bladder outlet obstruction. J Urol 178: 2035–2039 | Article | PubMed |
26. Seckiner I et al. (2006) A prospective randomized study for comparing bipolar plasmakinetic resection of the prostate with standard TURP. Urol Int 76: 139–143 | Article | PubMed | ISI |
27. Singh H et al. (2005) Bipolar versus monopolar transurethral resection of prostate: randomized controlled study. J Endourol 19: 333–338 | Article | PubMed |
28. Tefekli A et al. (2005) A hybrid technique using bipolar energy in transurethral prostate surgery: a prospective, randomized comparison. J Urol 174: 1339–1343 | Article | PubMed |
29. Yang S et al. (2004) Gyrus plasmasect: is it better than monopolar transurethral resection of prostate. Urol Int 73: 258–261 | Article | PubMed |
30. Nuhoglu B et al. (2006) Plasmakinetic prostate resection in the treatment of benign prostate hyperplasia: results of 1-year follow up. Int J Urol 13: 21–24 | Article | PubMed | ISI |
31. Patankar S et al. (2006) PlasmaKinetic Superpulse transurethral resection versus conventional transurethral resection of prostate. J Endourol 20: 215–219 | Article | PubMed |
32. Autorino R et al. (2007) Bipolar plasmakinetic technology for the treatment of symptomatic benign prostatic hyperplasia: evidence beyond marketing hype? BJU Int 100: 983–985 | PubMed |
33. Neill MG et al. (2006) Randomized trial comparing holmium laser enucleation of prostate with plasmakinetic enucleation of prostate for treatment of benign prostatic hyperplasia. Urology 68: 1020–1024 | Article | PubMed |
34. Elzayat EA and Elhilali MM (2007) Minimally invasive treatment of benign prostatic hyperplasia: laser. AUA Update Series 2007 26: lesson 27
35. Elzayat EA and Elhilali MM (2006) Laser treatment of symptomatic benign prostatic hyperplasia. World J Urol 24: 410–417 | Article | PubMed |
36. Kuntz RM (2007) Laser treatment of benign prostatic hyperplasia. World J Urol 25: 241–247 | Article | PubMed |
37. Gilling PJ et al. (1989) Holmium laser enucleation of the prostate (HoLEP) combined with transurethral tissue morcellation: an update on the early clinical experience. J Endourol 12: 457–459
38. Wilson LC et al. (2006) A randomised trial comparing holmium laser enucleation versus transurethral resection in the treatment of prostates larger than 40 grams: results at 2 years. Eur Urol 50: 569–573 | Article | PubMed | ISI |
39. Ahyai SA et al. (2007) Holmium laser enucleation versus transurethral resection of the prostate: 3-year follow-up results of a randomized clinical trial. Eur Urol 52: 1456–1463 | Article | PubMed |
40. Briganti A et al. (2006) Impact on sexual function of holmium laser enucleation versus transurethral resection of the prostate: results of a prospective, 2-center, randomized trial. J Urol 175: 1817–1821 | Article | PubMed |
41. Gupta N et al. (2006) Comparison of standard transurethral resection, transurethral vapour resection and holmium laser enucleation of the prostate for managing benign prostatic hyperplasia of >40 g. BJU Int 97: 85–89 | Article | PubMed |
42. Kuntz RM et al. (2004) Transurethral holmium laser enucleation of the prostate versus transurethral electrocautery resection of the prostate: a randomized prospective trial in 200 patients. J Urol 172: 1012–1016 | Article | PubMed |
43. Montorsi F et al. (2004) Holmium laser enucleation versus transurethral resection of the prostate: results from a 2-center, prospective, randomized trial in patients with obstructive benign prostatic hyperplasia. J Urol 172: 1926–1929 | Article | PubMed |
44. Rigatti L et al. (2006) Urodynamics after TURP and HoLEP in urodynamically obstructed patients: are there any differences at 1 year of follow-up? Urology 67: 1193–1198 | Article | PubMed |
45. Tan AH et al. (2003) A randomized trial comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for the treatment of bladder outlet obstruction secondary to benign prostatic hyperplasia in large glands (40 to 200 grams). J Urol 170: 1270–1274 | Article | PubMed | ChemPort |
46. Kuntz RM and Lehrich K (2002) Transurethral holmium laser enucleation versus transvesical open enucleation for prostate adenoma greater than 100 gm: a randomized prospective trial of 120 patients. J Urol 168: 1465–1469 | Article | PubMed |
47. Naspro R et al. (2006) Holmium laser enucleation of the prostate versus open prostatectomy for prostates >70 g: 24-month follow-up. Eur Urol 50: 563–568 | Article | PubMed |
48. Kuntz RM et al. (2008) Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial. Eur Urol 53: 160–166 | Article | PubMed |
49. Salonia A et al. (2006) Holmium laser enucleation versus open prostatectomy for benign prostatic hyperplasia: an inpatient cost analysis. Urology 68: 302–306 | Article | PubMed |
50. Elzayat EA et al. (2005) Holmium laser enucleation of prostate for patients in urinary retention. Urology 66: 789–793 | Article | PubMed |
51. Peterson MD et al. (2005) Holmium laser enucleation of the prostate for men with urinary retention. J Urol 174: 998–1001 | Article | PubMed |
52. Pedraza R et al. (2004) Holmium laser enucleation of the prostate in critically ill patients with technique modification. J Endourol 18: 795–798 | Article | PubMed |
53. Elzayat E et al. (2006) Holmium laser enucleation of the prostate in patients on anticoagulant therapy or with bleeding disorders. J Urol 175: 1428–1432 | Article | PubMed | ChemPort |
54. Kim SC et al. (2004) Simultaneous holmium laser enucleation of prostate and upper-tract endourologic stone procedures. J Endourol 18: 971–975 | Article | PubMed |
55. Shah HN et al. (2007) Simultaneous transurethral cystolithotripsy with holmium laser enucleation of the prostate: a prospective feasibility study and review of literature. BJU Int 99: 595–600 | Article | PubMed |
56. Bouchier-Hayes DM (2007) Photoselective vaporization of the prostate—towards a new standard. Prostate Cancer Prostatic Dis 10: 10–14 | Article |
57. Bachmann A et al. (2005) Photoselective vaporization (PVP) versus transurethral resection of the prostate (TURP): a prospective bi-centre study of perioperative morbidity and early functional outcome. Eur Urol 48: 965–971 | Article | PubMed | ISI |
58. Horasanli K et al. (2008) Photoselective potassium titanyl phosphate (KTP) laser vaporization versus transurethral resection of the prostate for prostates larger than 70 ml: a short-term prospective randomized trial. Urology 71: 247–251 | Article | PubMed |
59. Tasci AI et al. (2008) Rapid communication: photoselective vaporization of the prostate versus transurethral resection of the prostate for the large prostate: a prospective nonrandomized bicenter trial with 2-year follow-up. J Endourol 22: 347–353 | Article | PubMed |
60. Alivizatos G et al. (2007) Transurethral photoselective vaporization versus transvesical open enucleation for prostatic adenomas >80 ml: 12-mo results of a randomized prospective study. Eur Urol 54: 427–437 | Article | PubMed |
61. Ruszat R et al. (2006) Photoselective vaporization of the prostate: subgroup analysis of men with refractory urinary retention. Eur Urol 50: 1040–1049 | Article | PubMed | ISI |
62. Fu WJ et al. (2006) Evaluation of greenlight photoselective vaporization of the prostate for the treatment of high-risk patients with benign prostatic hyperplasia. Asian J Androl 8: 367–371 | Article | PubMed |
63. Ruszat R et al. (2007) Safety and effectiveness of photoselective vaporization of the prostate (PVP) in patients on ongoing oral anticoagulation. Eur Urol 51: 1031–1038 | Article | PubMed | ISI | ChemPort |
64. Stovsky MD et al. (2006) A clinical outcomes and cost analysis comparing photoselective vaporization of the prostate to alternative minimally invasive therapies and transurethral prostate resection for the treatment of benign prostatic hyperplasia. J Urol 176: 1500–1506 | Article | PubMed |
65. Xia SJ et al. (2008) Thulium laser versus standard transurethral resection of the prostate: a randomized prospective trial. Eur Urol 53: 382–389 | Article | PubMed |
66. Mariano MB et al. (2006) Laparoscopic prostatectomy for benign prostatic hyperplasia—a six-year experience. Eur Urol 49: 127–131 | Article | PubMed | ISI |
67. van Velthoven R et al. (2004) Laparoscopic extraperitoneal adenomectomy (Millin): pilot study on feasibility. Eur Urol 45: 103–109 | Article | PubMed | ChemPort |
68. Baumert H et al. (2006) Laparoscopic versus open simple prostatectomy: a comparative study. J Urol 175: 1691–1694 | Article | PubMed | ChemPort |
69. Porpiglia F et al. (2006) Transcapsular adenomectomy (Millin): a comparative study, extraperitoneal laparoscopy versus open surgery. Eur Urol 49: 120–126 | Article | PubMed |
70. Sotelo R et al. (2005) Laparoscopic retropubic simple prostatectomy. J Urol 173: 757–760 | Article | PubMed |
71. Vela-Navarrete R et al. (2005) The impact of medical therapy on surgery for benign prostatic hyperplasia: a study comparing changes in a decade (1992-2002). BJU Int 96: 1045–1048 | Article | PubMed |
72. Elzayat EA et al. (2005) Holmium laser enucleation of the prostate: a size-independent new "gold standard". Urology 66: 108–113 | Article | PubMed |
73. Kourambas J et al. Low-power holmium laser for the management of urinary tract calculi, structures, and tumors. J Endourol 15: 529–532
74. El-Hakim A and Elhilali MM (2002) Holmium laser enucleation of the prostate can be taught: the first learning experience. BJU Int 90: 863–869 | Article | PubMed | ChemPort |
75. Shah HN et al. (2007) Prospective evaluation of the learning curve for holmium laser enucleation of the prostate. J Urol 177: 1468–1474 | Article | PubMed | ISI |
76. Malek RS et al. (2005) Photoselective potassium-titanyl-phosphate laser vaporization of the benign obstructive prostate: observations on long-term outcomes.